Fill - Free fillable UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California) PDF form

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1101I01B 1114

UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee)

FILING INSTRUCTIONS

Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.

Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay

or prevent the ling of your claim, or cause benets to be denied. If the Employment Development Department (EDD) needs to

verify any of the information you provide while ling a claim, you will receive additional forms by mail and will be asked to provide

additional information and/or documentation.

APPLICATION QUESTIONS

The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a

false statement or withhold information.

1. Did you work in a state other than California during the

last 18 months?

Yes No If yes, check the applicable box(es) below:

State(s) Outside California, specify state(s):

AND / OR

Did you work in Canada during the last 18 months?

Canada

2. What is your Social Security number as given to you

by the Social Security Administration?

- -

a) If the EDD assigned you an EDD Client Number

(ECN), please provide the ECN here. (An ECN is a

9-digit number beginning with 999 or 990.)

- -

2A. List any other Social Security numbers you have used.

- - - -

3. What is your full name?

Last

First

Middle Initial

4. Is this the name that appears on your Social Security

card?

Yes No

a) If no, provide the name that appears on your

Social Security card.

Last

First

Middle Initial

5. List any other names you have used.

6. What is your birth date? (mm/dd/yyyy)

7. What is your gender?

Male Female

8. Would you prefer your written material in English or

Spanish?

English Spanish

a) What is your preferred spoken language?

9. Have you led a California Unemployment Insurance

or a Disability Insurance claim in the last two years?

Yes No

a) If yes, list each type of claim and the most recent

date(s) of when the claim(s) was led.

Unemployment Claim Date(s) (mm/dd/yyyy)

Disability Claim Date(s) (mm/dd/yyyy)

1.

2.

a)

2A.

3.

4.

a)

5.

6.

7.

8.

a)

9.

a)

CUDE 1101IB Rev. 4 (11-14) (INTERNET)

Page 2 of 12

1101I02

Social Security number: – –

10. Do you have a Driver License issued to you by a

State/entity?

Yes No

a) If yes, provide the name of the issuing State/entity

and your Driver License number.

Name of issuing State/entity:

Driver License Number:

If no, answer questions b-d:

b) Do you have an Identication Card issued to you

by a State/entity?

Y

es No

c) If yes, provide the name of the issuing State/entity

and your Identication Card number.

Name of issuing State/entity:

Identication Card Number:

d) How do you look for work and, if you have work,

how do you get to work?

Please Explain:

11. What is your telephone number? – –

a) If you are deaf, hard of hearing, or have a speech

disability and use TTY or California Relay to

communicate, check the appropriate box.

TTY (Non-voice) California Relay Service

12. What is your mailing address?

(Include your city, State, and ZIP code)

Street: Apt.:

City:

State: ZIP Code:

13. Is your residence address the same as your mailing

address?

Yes No

a) If no, enter your residence address. (Include your

city, State, ZIP code and apartment number.)

A

residence address cannot be a P.O. Box. Please

provide a street address.

Street: Apt.:

City:

State: ZIP Code:

14. If you do not live in California, what is the name of the

County in which you live?

15. What race or ethnic group do you identify with? Check one of the following:

White Black not Hispanic Hispanic

Asian American Indian/Alaskan Native Chinese

Cambodian Filipino Other Pacic Islander

Guamanian Asian Indian Japanese

Korean Laotian Samoan

Vietnamese Hawaiian I choose not to answer

16. Do you have a disability? (A disability is a physical or

mental impairment that substantially limits one or more

life activities, such as caring for oneself, performing

manual tasks, walking, seeing, hearing, speaking,

breathing, learning, or working.)

Yes No I choose not to answer

17. What is the highest grade of school you have completed? Check only one box.

Did not complete High School High School Diploma or GED Some college or vocational school

Associate of Arts Bachelor of Arts or Science Masters or Doctorate

18. Are you a Military Veteran?

Yes No

UNEMPLOYMENT INSURANCE APPLICATION

10.

a)

If no, answer questions b-d:

b)

c)

d)

11.

a)

12.

13.

a)

14.

16.

18.

DE 1101IB Rev. 4 (11-14) (INTERNET)

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1101I03

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

19. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an

agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported

under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

a) Name and mailing address of all employers you worked for in the last 18 months.

b) Period of employment (Dates W

orked).

c) Total Wages earned for each employer in the last 18 months.

d) How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).

e) Specify if you worked full-time or part-time.

f) How many hours you worked per week.

g) Check the appropriate “Y

es/No” box if the employer is (or is not) a school or educational institution or a public or nonprot employer

where you performed school-related work.

NOTE:

It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to

provide complete information will result in your benets being delayed or denied.

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 4 of 12

c)

1101I04

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

19. Continued

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

b) Dates Worked

From:

To:

c) Total Wages

$

d) How were you paid?

(e.g.,weekly, monthly, etc.)?

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

20. During the past 18 months did you work for any other

employers not listed in question 19?

20 Yes No

If yes, list the employer information for questions 19 a-g on a separate sheet of

paper. Attach the additional sheet of paper to this application.

21. If the EDD nds that you do not have sufcient wages

in the Standard Base Period to establish a valid claim,

do you want to attempt to establish a claim using the

Alternate Base Period?

For additional information about the Standard Base

Period and the Alternate Base Period, visit the EDD

website www.edd.ca.gov.

21 Yes No

22. During the past 18 months, which employer did you

work for the longest?

22. Employer name:

a) What type of business was operated by the

employer? (Please be specic. For example,

restaurant, dry cleaning, construction, book store.)

a) Type of business:

b) How long did you work for that employer? b) Years: Months:

c) What type of work did you do for that employer?

c)

23. What is your usual occupation? 23.

24. Is your usual work seasonal?

24. Yes No

If yes, answer questions a-c:

a) When does the season usually begin?

a) (mm/dd/yyyy)

b) When does the season usually end?

b) (mm/dd/yyyy)

c) What other work-related skills do you have?

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 5 of 12

1101I05

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

Please provide information about your very last employer. This is the employer you last worked for regardless of the length of

time you worked at that job, the type of work you did for that employer, or whether or not you have been paid.

If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are

reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home

Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not

the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Reminder: To le a claim, individuals must be out of work or working less than full time. You must provide information about the

last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.

25. What is the last date you actually worked for your very

last employer?

25. (mm/dd/yyyy)

a) What are your gross wages for your last week of

work? For Unemployment Insurance purposes, a

week begins on Sunday and ends the following

Saturday.

a) $

b) What is the complete name of your very last

employer?

b) Name:

c) What is the mailing address of your very last

employer?

c) Mailing address:

Street:

City:

State: ZIP Code:

d) Is the physical address of your very last employer

the same as their mailing address? (A physical

address cannot be a P.O. Box. Please provide a

street address.)

d) Yes No

If no, what is the physical address of your very

last employer?

Physical address:

Street:

City:

State: ZIP Code:

e) What is the telephone number of your very last

employer at their physical address?

e) – –

f) What is the name of your immediate supervisor?

f)

g) Briey explain in your own words the reason

you are no longer working for your very last

employer, within the space provided. Please do

not include any attachments.

g) Reason:

26. Are you (directly or indirectly) out of work with any

employer (last employer or any employer in the last

18 months) due to a trade dispute, such as a strike or

a lockout?

26. Yes No

If yes and a union was/is involved, answer

questions a-b:

a) What is the name and telephone number of the

union?

Name:

Phone: – –

b) Are you going to receive strike benets?

Yes No

If yes and a union was not/is not involved, answer questions c-e:

c) How many employees left work?

d) Was there a spokesperson for the employees? Yes No

e) If yes, what is his/her name and telephone number?

Name:

Phone: – –

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 6 of 12

1101I06

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

27. Are you currently working for or do you expect to work

for any school or educational institution or a public or

nonprot employer performing school-related work?

27. Yes No

If yes, answer questions a-e:

a) Provide the following information for the school or

educational institution(s) or the public or nonprot

employer(s).

a)

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

Phone: – –

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

Phone: – –

b) Are you a substitute teacher for Los Angeles

Unied School District (LAUSD)?

b) Yes No

c) Are you currently in a recess period or off track?

c) Yes No

d) Do you have reasonable assurance to return to

work after the recess period or the off track period

with any school or educational institution?

d) Yes No

If yes, when? (mm/dd/yyyy)

e) What is the beginning date of your next recess or

the next off track period?

e) (mm/dd/yyyy)

28. Do you expect to return to work for any former

employer?

28. Yes No

29. Do you have a date to start work with any employer?

29. Yes No

If yes, answer question a:

a)

a) What date will you start work?

(mm/dd/yyyy)

30. Are you a member of a union or non-union trade

association?

30. Yes No

If yes, answer questions a-f:

a) What is the name of your union or non-union

organization?

a)

b) What is your union local number?

b)

(Enter zero “0” for non-union trade association.)

c) What is the telephone number of your union or

non-union trade association?

c) – –

d) Does your union or non-union trade association

nd work for you?

d) Yes No

e) Does your union or non-union trade association

control your hiring?

e) Yes No

f) Are you registered with your union or non-union

trade association as out of work?

f) Yes No

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 7 of 12

1101I07

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

31. Are you currently attending, or do you plan on

attending school or training?

31. Yes No

If yes, answer question a-g:

If yes, answer questions a-g:

a) What is the starting date of the school or training?

a)

(mm/dd/yyyy)

b) What is the ending date of the current session?

b) (mm/dd/yyyy)

c) What is the name of the school?

c)

d) What is the telephone number of the school?

d)

Phone: – –

e) What are the days and hours you are attending, or

plan to attend, school?

e)

Days and hours:

f) Is your school or training program authorized or

funded by one of the programs listed in section f?

NOTE: If you are in a State Approved Apprenticeship

training, you must mail your training completion

certicate with your Continued Claim Form,

DE 4581, for the week(s) of training.

f) Yes No

If yes, check only one box.

Workforce Investment Act (WIA)

Employment Training Panel (ETP)

Trade Adjustment Assistance (TAA)

California Work Opportunity and Responsibility to Kids

(CalWORKS)

State Approved Apprenticeship

Union or Non-union Journey Level

None of the above

g) If you had a job, or were offered a job in your

usual occupation, would the days and hours you

attend school prevent you from working full time?

g) Yes No

32. Are you available for immediate full-time work in your

usual occupation?

32. Yes No

a) If no, please explain why you are not available for

full-time work.

a) Explanation:

33. Are you available for immediate part-time work in your

usual occupation?

33. Yes No

a) If no, please explain why you are not available for

part-time work.

a) Explanation:

34. Are you currently self-employed, or do you plan to

become self-employed? (Self-employment means

you have your own business or work as an

independent contractor.)

34. Yes No

35. Are you now, or have you been in the last 18 months

an ofcer of a corporation or union or the sole or major

stockholder of a corporation?

35. Yes No

a) If yes, include name of organization and your title

or position.

a) Name of Organization:

Title/Position:

36. Did you serve as an elected public ofcial or

Governor-exempt appointee in the last 18 months?

36. Yes No

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 8 of 12

1101I08

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

37. Are you currently receiving a pension?

37. Yes No

If yes, answer question a:

a) Are you currently receiving more than one pension?

a) Yes No

If yes, proceed to question 38.

If no, answer questions b-f:

If yes, proceed to question 38.

If no, answer questions b-f:

b) What is the name of the pension provider?

b)

c) Is the pension based on another person’s work or

wages?

c) Yes No

d) Is the pension a union pension or a pension

funded by more than one employer?

d) Yes No

e) What is the name of the employer(s) paying into

the pension?

e)

f) Did you work for that employer in the last

18 months?

f) Yes No

38. Will you receive any additional pension(s) in the next

12 months?

38. Yes No

If yes, answer questions a-b:

a) What is the name of the pension provider(s)?

a)

b) When will you receive the pension(s)?

b) (mm/dd/yyyy)

(mm/dd/yyyy)

39. Are you receiving, or do you expect to receive,

Workers’ Compensation?

39. Yes No

If yes, answer questions a-d:

a) Who is the insurance carrier?

a)

b) What is the insurance carrier’s telephone number?

b) Phone: – –

c) What is the case number, if known?

c)

d) What are the dates of your claim, if known?

From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

d)

40. Have you received or do you expect to receive, any payments from your last employer, other than your

regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)

Yes No

If yes, provide the information in sections A-D. If you received severance pay as a lump sum, complete sections A-C (in section C, report

the date the lump-sum payment was made).

A.

TYPE OF PAYMENT

(Example: vacation pay)

B.

AMOUNT OF PAYMENT

(Example: $600)

C.

PAID FROM

(Date: mm/dd/yyyy)

D.

PAID TO

(Date: mm/dd/yyyy)

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 9 of 12

1101I09

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

41. Are you a U. S. Citizen or National?

41. Yes No

If no, answer question a:

a) Are you registered with the United States

Citizenship and Immigration Services (USCIS,

formerly INS) and authorized to work in the

United States?

a) Yes No

b) Were you legally entitled to work in the United

States for the last 19 months?

b) Yes No

IMPORTANT: If you answered “yes” to question “a” above, you must select one of the USCIS documents listed in 41A through 41H

below and provide the applicable document information.

41A. Permanent Resident Card (I-551)

1) Alien Registration Number (A#)

2) Permanent Resident Card Number (CARD#)

NOTE: The CARD# is on the back of the card, next to

your photo, under the DOB and the EXP date.

3) Expiration Date (EXP)

41A. Permanent Resident Card (I-551)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2)

The CARD# must be 13 characters long. Enter 3 alphabetic characters

followed by 10 numeric digits. If your current card was issued to you

before December 1997, leave this blank.

3) (mm/dd/yyyy)

41B. Employment Authorization Card (I-766)

1) Alien Registration Number (A#)

2) Expiration Date

41B. Employment Authorization Card (I-766)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

41C. Refugee Travel Document (I-571)

1) Alien Registration Number (A#)

2) Expiration Date

41C. Refugee Travel Document (I-571)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 10 of 12

1101I10

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

41D. Arrival/Departure Record (I-94)

1) Arrival/Departure Number

2) Expiration Date

41D. Arrival/Departure Record (I-94)

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2)

(mm/dd/yyyy)

41E. Re-entry Permit (I-327)

1) Alien Registration Number (A#)

2) Expiration Date

41E. Re-entry Permit (I-327)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2)

(mm/dd/yyyy)

41F. Unexpired Foreign Passport

1) Arrival/Departure Number

2) Passport Number

3) Visa Number

4) Expiration Date

41F. Unexpired Foreign Passport

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2)

The passport number must be 6 to 12 alphanumeric characters. It is

usually found on the top right corner of the document.

3)

The Visa Number must be 8 numeric digits.

4)

(mm/dd/yyyy)

41G. Arrival/Departure Record (I94) in Unexpired

Foreign Passport

1) Arrival/Departure Number

2) Passport Number

3) Visa Number

4) Expiration Date

41G. Arrival/Departure Record (I94) in Unexpired Foreign Passport

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2)

The passport number must be 6 to 12 alphanumeric characters. It is

usually found on the top right corner of the document.

3)

The Visa Number must be 8 numeric digits.

4) (mm/dd/yyyy)

41H. Other Document (not listed in Section A to G)

1) Alien Registration Number (A#)

2) Arrival/Departure Number

3) Expiration Date

4) Document Description

41H. Other Document (not listed in Section A to G)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

3) (mm/dd/yyyy)

4) Document Description:

DE 1101IB Rev. 4 (11-14) (INTERNET)

Page 11 of 12

1101I11

Social Security number: – –

SUPPLEMENTAL FORM FOR FEDERAL EMPLOYEES – ATTACHMENT B

Please complete the following:

1. Did you work for the Federal Emergency

Management Agency (FEMA) as a Disaster Assistance

Employee (DAE)?

Yes No

2. What is your state of residence?

3. What is the complete name of the federal agency for

your last ofcial duty station?

Name:

a) What is the complete address of the federal

agency for your last ofcial duty station?

Address:

Street:

City:

State: ZIP Code:

4. What is your employer’s three-digit Federal

Identication Code (FIC) located on your W-2, SF 8 or

SF 50?

a) What is the federal agency name and address on

your W-2, SF 8 or SF 50?

Name:

Address:

Street:

City:

State: ZIP Code:

5. Have you had subsequent employment since your

federal employment?

Yes No

a) If yes, in what state was your subsequent

employment?

DE 1101IB Rev. 4 (11-14) (INTERNET)

UNEMPLOYMENT INSURANCE APPLICATION

1.

2.

3.

a)

4.

a)

5.

a)

Page 12 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

DO NOT MAIL OR FAX THIS PAGE

SUBMITTING YOUR APPLICATION

Be sure to review your application thoroughly for completeness. An incomplete application may delay or prevent the ling of your

claim, or cause benets to be denied.

Submit your completed application including any applicable attachment(s) by mail or fax:

By MAIL to the following address: EDD

P.O. Box 12906

Oakland, CA 94604-2909

NOTE: Extra postage is required.

By FAX to the following telephone number: 1-866-215-9159

Once you submit your application, allow 10 days for processing of your claim. You will receive Unemployment Insurance

(UI) claim materials by mail. If you have not received any UI claim materials after 10 days from the date you submitted your

application, call one of the following toll-free telephone numbers:

English 1-800-300-5616 Spanish 1-800-326-8937 Mandarin 1-866-303-0706

TTY (Non Voice) 1-800-815-9387 Cantonese 1-800-547-3506 Vietnamese 1-800-547-2058

Date Submitted: by Mail or Fax

KEEP THIS PAGE FOR YOUR RECORDS

DE 1101IB Rev. 4 (11-14) (INTERNET)

Fill Online, Printable, Fillable, Blank UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California) Form

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Fillable UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California)

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